Table 25

Investigation and management of nausea

InvestigationsPotential resultsClinical management plan
Actions from history, medication and dietary assessment
History findingsSymptoms of heart burn/acid/bile reflux
  1. See management of acid or bile related inflammation (p. 25).

  2. Reassess after 2–4 weeks as clinically indicated.

With dizziness/sweating/palpitationsSee page 20.
Headache/neurological symptoms presentNeurological examination. Funduscopy and CT/MRI head.
Poor fluid intakeCheck renal function/encourage fluids.
Constipation/impactionAXR. See management of constipation (p. 26).
Medication findingsOpiates
ChemotherapyContact team to change antiemetics urgently. If multiple vomiting daily this is an emergency. Contact the on-call acute oncology team.
Dietary findingsNutritional compromiseRefer for dietetic advice.
First line
FunduscopyRaised ICPThis is an emergency. Discuss immediately with the supervising clinician and oncology or neurology team.
Routine and additional blood testsMetabolic abnormalityDiscuss immediately with the supervising clinician.
Liver/biliary abnormalityDiscuss with the supervising clinician within 24 hours.
Suggestive of infectionTreat with antibiotics within level of confidence or discuss with microbiologist or supervising clinician.
Urine analysisMetabolic abnormality, eg, glucosuria, ketonuriaDiscuss immediately with supervising clinician.
InfectionTreat with antibiotics within level of confidence or discuss with a microbiologist or supervising clinician within 24 hours.
Second line
OGD and SI aspirate (p. 25)Upper GI inflammation/ulcerationSee management of acid or bile related inflammation (p. 25).
Gastric dysmotilityConsider prokinetic medication (p. 26).
Pyloric stenosisRefer urgently to the appropriate cancer MDT.
Bleeding peptic ulcerThis is an emergency. Discuss immediately with the supervising clinician/gastroenterologist.
SIBOManagement of SIBO (p. 27).
Glucose hydrogen methane breath testSIBOManagement of SIBO (p. 27).
US liver and pancreasBiliary/hepatic/pancreatic aetiologySee management of jaundice on p. 18.
Cortisol levelAddison's diseaseConfirm with the Synacthen test, start on hydrocortisone and refer to endocrinology.
US/CT/MRI/PETMalignancy/tumour recurrence/lymphadenopathyDiscuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
Consider also
  1. Internal hernia (if Roux-en-Y)

  2. Jejunal tube complication, eg, volvulus (if still in situ)

  3. Pancreatitis

These are emergencies. Refer to upper GI surgical team.
Mesenteric ischaemiaThis is an emergency. Discuss with the on-call surgical team immediately.
AscitesDiscuss with the supervising clinician and the oncology team within 24 hours.
Third line
If normal investigations/no response to intervention
  1. Consider contributing psychological factors.

  2. Consider referral for psychological support if there is a possible underlying eating disorder.

  3. Consider a routine referral to gastroenterology for further management.

  • AXR, abdominal X-ray; CT, computerised tomography; GI, gastrointestinal; ICP, intracranial pressure; MDT, multidisciplinary team; NSAID, non-steroidal anti-inflammatory drug; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PET, positron emission tomography; SIBO, small intestinal bacterial overgrowth; US, ultrasound.